Methods of conservative (tires, Methods of conservative (tires, caps) and operational caps) and operational
(osteosynthesis, apparatus) (osteosynthesis, apparatus) treatment of the facial skull treatment of the facial skull
fractures. Types of healing of the fractures. Types of healing of the jaws fractures. Complications of jaws fractures. Complications of the MFA damages: hemorrhage, the MFA damages: hemorrhage,
asphyxia, shock syndrome. Crush asphyxia, shock syndrome. Crush facial tissue.facial tissue.
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Facial InjuriesFacial Injuries
Lower Level fractures (Le-Fort I, Lower Level fractures (Le-Fort I, TransverseTransverse, Guerin), Guerin)transverse fracture separating the maxillary alveolus from the transverse fracture separating the maxillary alveolus from the upper mid faceupper mid face
Upper Level FracturesUpper Level FracturesLe-Fort II(Le-Fort II(Pyramidal Pyramidal fracture) : fracture) : separates a pyramid-shaped separates a pyramid-shaped central fragment containing the maxillary dentition from the central fragment containing the maxillary dentition from the remainder of the orbits and upper craniofacial skeletonremainder of the orbits and upper craniofacial skeleton
Le-Fort III (Le-Fort III (craniofacial dysjunctioncraniofacial dysjunction) : ) : separates the maxilla at separates the maxilla at the level of the upper portion of the zygoma, orbital floor, and the level of the upper portion of the zygoma, orbital floor, and nasoethmoid region from the remainder of the upper nasoethmoid region from the remainder of the upper craniofacial skeletoncraniofacial skeleton
Midface Fractures
Le-Fort Maxillary Fractures
Le-Fort Maxillary Fractures
Maxillary FracturesMaxillary FracturesSymptoms and SignsSymptoms and Signs
Periorbital hematomaPeriorbital hematomaNasopharyngeal bleedingNasopharyngeal bleedingPainPainSwelling on the faceSwelling on the faceIntraoral lacerationsIntraoral lacerationsMalocclusionMalocclusionElongation of the faceElongation of the faceMaxillary retrusionMaxillary retrusionAnterior open biteAnterior open biteAbnormal mobility on the dental arcAbnormal mobility on the dental arcRinorea and pneumocephaly (% 25 in LeFort II and III)Rinorea and pneumocephaly (% 25 in LeFort II and III)
Dental Occlusion
Normal occlusion Mandibular retrognathia Mandibular prognathia
Bimanual maxillary examination for abnormal movement
ImagingImagingPlain radiographs : Waters’ and lateral view
Axial and coronal CT scans of the midface
3 D CT
Waters’ radiograph Coronal CT3D CT
Dish-shaped face, loss of facial projection, bilateral conjunctival hemoraji
Treatment of Maxilla Fractures
Open reduction and intermaxillary fixation and spanning each of the butresses with plate and screws
Orbital FracturesOrbital Fractures
ClassificationClassificationOrbital floor blow-out fracturesOrbital floor blow-out fractures
Pure (nonfractured infraorbital rim)Pure (nonfractured infraorbital rim)
Inpure (fractured infraorbital rim)Inpure (fractured infraorbital rim)
Orbital fractures (without blow-out)Orbital fractures (without blow-out)Lineer fracturesLineer fractures
Combined with maxillary fracturesCombined with maxillary fractures
Zygomatic fracturesZygomatic fractures
A- small orbital blow-out fracture is confined to the orbital floor
B- larger blow-out fracture extends to involve to the lower medial orbit as well as orbital floor
Bone graft for repair of medial blow-out fracture
Symptom and Signs Symptom and Signs
palpebral and subconjunctival hematomapalpebral and subconjunctival hematomaDiplopia (Diplopia (most common looking superiorly or inferiorlymost common looking superiorly or inferiorly))
Numbness in the inferior orbital nerve Numbness in the inferior orbital nerve distributiondistributionEnophthalmosEnophthalmosPositive forced duction testPositive forced duction testRadiological evidence of orbital floor fracture Radiological evidence of orbital floor fracture and entrapment of soft tissues on the and entrapment of soft tissues on the CT scans CT scans with both axial and coronal viewswith both axial and coronal viewsAssessment of the visual system Assessment of the visual system is essentialis essential
Treatment of Orbital Blow-out Treatment of Orbital Blow-out FractureFracture
There are two major surgical indications for There are two major surgical indications for orbital fracture repairorbital fracture repair
Muscle entrapment Muscle entrapment ((confirmed by forced duction and CT scanconfirmed by forced duction and CT scan))
volume increasevolume increase (> 2cm(> 2cm2 2 defects enophthalmos and globe defects enophthalmos and globe dystopia developes)dystopia developes)
Subciliar or transconjunctival approachSubciliar or transconjunctival approach
Entrapped soft tissues are brought back from maxiillary Entrapped soft tissues are brought back from maxiillary sinussinus
Defect are bridged with bone grafts or alloplastic Defect are bridged with bone grafts or alloplastic materials(silicone, titanium mesh, medpor, proplast etc.)materials(silicone, titanium mesh, medpor, proplast etc.)
The Superior Orbital Fissure and Orbital The Superior Orbital Fissure and Orbital Apex SyndromeApex Syndrome
ptosis of the eyelidptosis of the eyelid proptosis of the globeproptosis of the globe paralysis of cranial nerve III, IV, and VIparalysis of cranial nerve III, IV, and VI anesthesia in the distribution of the first anesthesia in the distribution of the first division of the trigeminal nervedivision of the trigeminal nerveIf blindness occurs in combination with the If blindness occurs in combination with the superior orbital fissure syndrome, the superior orbital fissure syndrome, the condition is termed the “orbital apex condition is termed the “orbital apex syndrome.”syndrome.”
Nasoethmoidal Orbital Fractures Nasoethmoidal Orbital Fractures
Symptoms and signsSymptoms and signsTelecanthusTelecanthus
Decrease in the dorsal nasal projectionDecrease in the dorsal nasal projection
RinoreaRinorea
Treatment:Treatment:open reduction with a open reduction with a combination of interfragmentary wiring and combination of interfragmentary wiring and plate and screw fixationplate and screw fixation
Nasoethmoidal Orbital Fractures Nasoethmoidal Orbital Fractures and their treatmentand their treatment
periorbital ecchymosis, edema, antimongoloid slant, and subconjunctival hemorrhage.
FrontalWorm’s-eye view.
Axial CT scan
isolated depressed left zygomatic arch fracture.
Treatment of zygomatic fracture with Gillies method
TREATMENT
Open reduction and rigid fixation with plates and screws at frontozygomatic suture, inferior orbital rim, and zygomatico-
maxillary butress
Various types of fractures of nasal
bones
Hematoma of Septum
SymptomsSymptoms
PainPainSwelling Swelling Respiratory obstructionRespiratory obstructionCrepitation on palpationCrepitation on palpation Nasal deformityNasal deformityDeviation of the septumDeviation of the septumMucosal lacerations intranasally Mucosal lacerations intranasally Septal hematoma Septal hematoma
Reduction of nasal fracture with an Asch forceps
Mandibular FracturesMandibular Fractures
the second most common facial bone injurythe second most common facial bone injuryMandibular fractures are classified according to Mandibular fractures are classified according to the state of the dentition (dentulous, partially the state of the dentition (dentulous, partially dentulous, edentulous) dentulous, edentulous) or or the region of the the region of the mandible in which the fracture occurs (condyle, mandible in which the fracture occurs (condyle, condylar neck, ramus, coronoid, angle, body, condylar neck, ramus, coronoid, angle, body, symphysis)symphysis)TThey are classified as either open or closed, hey are classified as either open or closed, depending on whether or not they have a depending on whether or not they have a communication with a skin lacerationcommunication with a skin laceration
Anatomic regions and frequency of fractures in those regions
•subcondylar area
•angle region weakened by the presence of the third molar tooth
•the parasymphysis weakened by mental foramen and canine where the long root of the cuspid tooth
Symptoms and SignsSymptoms and Signs
PainPainSwellingSwellingTTendernessendernessMalocclusionMalocclusionFrequently, the patient volunteers that the teeth Frequently, the patient volunteers that the teeth do not feel like they are “coming together do not feel like they are “coming together properly.” properly.” Numbness in the distribution of the mental nerveNumbness in the distribution of the mental nerve
Fractured teeth, gaps, or level discrepancies in dentition, Fractured teeth, gaps, or level discrepancies in dentition, asymmetries of the dental arch, the presence of intraoral asymmetries of the dental arch, the presence of intraoral lacerations, loose teeth, and crepitance indicate the possibility of lacerations, loose teeth, and crepitance indicate the possibility of a mandibular fracturea mandibular fracture
Panorex examinationPanorex examination of mandible of mandible
Intermaxillary fixation
Treatment of mandibular fracture by application of an arch bar and plating at the inferior border
Osteosynthesis (internal fixation) refers to Osteosynthesis (internal fixation) refers to placement of wires, screws, plates, rods, placement of wires, screws, plates, rods, pins & other hardware directly to the bones pins & other hardware directly to the bones to help stabilize a fracture. to help stabilize a fracture.
Mechanical devices- wires, rods, pins, Mechanical devices- wires, rods, pins, screws and plates.screws and plates.
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INDICATIONSINDICATIONS
Trauma- facial bone fractureTrauma- facial bone fractureOrthognathic surgeryOrthognathic surgeryReconstruction of craniofacial deformitiesReconstruction of craniofacial deformitiesReconstruction of bony defects 2 F to ablative Reconstruction of bony defects 2 F to ablative
tumour surgery.tumour surgery.Augmentation of atrophic mandible in the Augmentation of atrophic mandible in the
elderlyelderly Iatrogenic -2 F to anterior/lateral Iatrogenic -2 F to anterior/lateral
mandibulotomy mandibulotomy
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MATERIALSMATERIALS
Metallic and Resorbable(biodegradable) Metallic and Resorbable(biodegradable) osteosynthetic devices.osteosynthetic devices.
1.Metallic 1.Metallic Stainless steelStainless steelVitallium- trade name for alloy of chromium, Vitallium- trade name for alloy of chromium, cobalt & molybdeniumcobalt & molybdeniumTitanium Titanium
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MATERIALSMATERIALS
Stainless steel-has been abandoned due to Stainless steel-has been abandoned due to corrosion & potential toxicitycorrosion & potential toxicity
Vitallium- used by Luhr plate systemVitallium- used by Luhr plate system
Tensile strenght ↑ than titaniumTensile strenght ↑ than titanium
Biocompatible but does not osteointegrateBiocompatible but does not osteointegrate
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MATERIALSMATERIALS
TitaniumTitaniumTi-6Al-4V= 6% Aluminium+ 4% VanadiumTi-6Al-4V= 6% Aluminium+ 4% VanadiumTi-6Al-7Nb= 6% Aluminium+ 7% NiobiumTi-6Al-7Nb= 6% Aluminium+ 7% NiobiumBest corrosion resistanceBest corrosion resistanceBiocompatible Biocompatible OsteointegrateOsteointegrateIn comparison with the other materials, In comparison with the other materials, offers least interference with MRI.offers least interference with MRI.
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BIOMECHANICSBIOMECHANICS
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BiomechanicsBiomechanics
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BiomechanicsBiomechanics
Ideal osteosynthesis line of Ideal osteosynthesis line of mandible(Champy’s) mandible(Champy’s)
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Load-bearing fixationLoad-bearing fixation
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Load-sharing fixationLoad-sharing fixation
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compression platescompression plates
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Locking plate systemLocking plate system
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INSTRUMENTATIONINSTRUMENTATION Reduction forcepsReduction forceps
Towel clip typeTowel clip typeBone holding clampsBone holding clampsReduction/Compression forcepsReduction/Compression forceps
Plate holding forcepsPlate holding forceps Screw driver ± holding sleeve (hexa, cruciform, Screw driver ± holding sleeve (hexa, cruciform,
phillip)phillip) Plate bendersPlate benders
Bending ironsBending ironsBending pliers (flat, pronged, side bender)Bending pliers (flat, pronged, side bender)
Plate cuttersPlate cutters Templates Templates
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INSTRUMENTATION INSTRUMENTATION (CONTINUED)(CONTINUED)
Drilling machineDrilling machine
Drill bitsDrill bits
Drill guides (neutral or eccentric)Drill guides (neutral or eccentric)
Depth guagesDepth guages
Tap Tap
Transbuccal instruments (trocar + Transbuccal instruments (trocar + cannula, guide, retractor)cannula, guide, retractor)
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UFPUFP
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BODYBODY
Lag screwsLag screws
One miniplateOne miniplate
Two platesTwo plates
One large plate (recon. Plate)One large plate (recon. Plate)
3D plates3D plates
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ANGLE AND RAMUSANGLE AND RAMUS
Single miniplateSingle miniplate– Oblique ridgeOblique ridge– Buccal surfaceBuccal surface
Two miniplatesTwo miniplates
3D plates3D plates
Reconstruction plateReconstruction plate
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CONDYLECONDYLE
Ideally, two miniplates should be applied in Ideally, two miniplates should be applied in a triangular fashion with one plate below a triangular fashion with one plate below the sigmoid notch and one plate along the the sigmoid notch and one plate along the posterior border.posterior border.
Single DCPSingle DCP
Single large profile 2.0 mand plateSingle large profile 2.0 mand plate
3D plate3D plate
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Parasymphyseal fractureParasymphyseal fracture
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Parasymphyseal fractureParasymphyseal fracture
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Angle fractureAngle fracture
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Defect bridgingDefect bridging
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Primary reconstructionPrimary reconstruction
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THANK YOU FOR THANK YOU FOR ATTENTIONATTENTION